Special Notes Implementation Date by CO. State CG number CG title CG Category Original Current Version

Transcription

1 Anthem Blue Cross and Blue Shield Approved and adopted corporate Clinical Utilization Management (UM) Guidelines COLORADO Updated August 17, 2018 NOTE: Any Clinical Guideline not included in this standard adopted list that is needed to complete an ASO group-specific review requirement will be considered Adopted for that ASO group only and for the specific type of review required. Additionally, as part of the Pre-Payment Review Program for commercial or Federal Employee Health Benefits Program (FEHBP) plans, Clinical Guidelines approved by Medical Policy and Technology Assessment Committee (MPTAC) but not included in this standard adopted list may be used to review a provider s claims when a provider s billing practices are not consistent with other providers in terms of frequency or in some other manner or for provider education and are Adopted for those purposes. State CG number CG title CG Category Original Current Version Special Notes Implementation Date by CO Implementation Date** CO CG-ADMIN-02 Clinically Equivalent Cost Effective Services Targeted Immune Administrative 7/1/2018 8/29/2018 Modulators CO CG-ANC-04 Ambulance Services: Air and Water Ancillary/Miscellaneous 4/16/2013 2/28/2018 CO CG-ANC-06 Ambulance Services: Ground, Non-Emergent Ancillary/Miscellaneous 12/1/2014 8/29/2018 CO CG-BEH-01 Screening and Assessment for Autism Spectrum Disorders and Rett Behavioral Health 7/1/2013 3/29/2018 Syndrome CO CG-BEH-03 Psychiatric Disorder Treatment Behavioral Health 9/9/2016 4/25/2018 Archive 10/31/2018 CO CG-BEH-04 Substance-Related and Addictive Disorder Treatment Behavioral Health 2/4/2016 3/29/2018 Archive 10/31/2018 CO CG-BEH-05 Eating and Feeding Disorder Treatment Behavioral Health 2/4/2016 3/29/2018 CO CG-BEH-15 Activity Therapy for Autism Spectrum Disorders and Rett Syndrome Behavioral Health 6/28/2018 6/28/2018 CO CG-DME-07 Augmentative and Alternative Communication (AAC) Devices/Speech Generating Devices (SGD) Pre-service E1902, E2351 Post Service: CPT Codes 92605, 92606, 92607, 92608, 92609; HCPCS Code V5336 Durable Medical Equipment 10/9/2012 8/29/2018 CO CG-DME-10 Durable Medical Equipment Durable Medical Equipment 7/1/2013 3/29/2018 CO CG-DME-31 Wheeled Mobility Devices: Wheelchairs-Powered, Motorized, With or Durable Medical Equipment 7/1/2013 3/15/2018 Without Power Seating Systems and Power Operated Vehicles (POVs) CO CG-DME-33 Wheeled Mobility Devices: Manual Wheelchairs - Ultra Lightweight Durable Medical Equipment 4/16/2013 3/29/2018 CO CG-DME-40 Electical Bone Growth Stimulation Durable Medical Equipment 12/27/ /27/2017 CO CG-DME-41 Ultraviolet Light Therapy Delivery Devices for Home Use Durable Medical Equipment 12/27/ /17/2018 CO CG-DME-42 Non-implantable Insulin Infusion and Blood Glucose Monitoring Durable Medical Equipment 5/1/ /17/2018 Devices CO CG-DME-43 Oscillatory Devices for Airway Clearance (High Frequency Chest Compression) Durable Medical Equipment 5/1/2018 5/1/2018 CO CG-DME-44 Electric Tumor Treatment Field (TTF) Durable Medical Equipment 6/28/2018 6/28/2018 CO CG-DRUG-01 Off-Label Drug and Approved Orphan Drug Use Precription Drug 1/8/2013 3/29/2018 CO CG-DRUG-03 Beta-Interferons and Glatiramer Acetate for Treatment of Multiple Precription Drug 4/1/ /17/2018 Sclerosis CO CG-DRUG-05 Recombinant Erythropoietin Products Precription Drug 1/1/2013 8/29/2018 CO CG-DRUG-08 Pharmacotherapy for Gaucher Disease Precription Drug 1/1/ /17/2018 CO CG-DRUG-09 Immune Globulin (Ig) Therapy Precription Drug 4/1/2013 8/29/2018 CO CG-DRUG-11 Infertility Drugs Precription Drug 1/8/2013 8/29/2018 CO CG-DRUG-16 White Blood Cell Growth Factor Precription Drug 7/9/2013 6/28/2018 CO CG-DRUG-24 Repository Corticotropin Injection (H.P. Acthar Gel) Precription Drug 1/8/2013 8/29/2018 CO CG-DRUG-25 Intravenous versus Oral Drug Administration Precription Drug 7/9/2013 6/6/2018 CO CG-DRUG-28 Alglucosidase alfa (Lumizyme ) Precription Drug 7/9/2013 2/28/2018 CO CG-DRUG-29 Hyaluronan Injections Precription Drug 12/1/2017 5/1/2018 CO CG-DRUG-38 Pemetrexed (Alimta ) Precription Drug 1/1/ /27/2017 CO CG-DRUG-42 Asparagine Specific Enzymes (Asparaginase) Precription Drug 7/1/ /27/2017 CO CG-DRUG-43 Natalizumab (Tysabri ) Precription Drug 1/1/2017 3/29/2018 CO CG-DRUG-44 Pegloticase (Krystexxa ) Precription Drug 6/1/2018 6/1/2018 CO CG-DRUG-45 Octreotide Acetate (Sandostatin, Sandostatin LAR Precription Drug 3/1/ /27/2017 CO CG-DRUG-49 Doxorubicin Hydrochloride Liposome Injection Drug 1/1/2017 6/6/2018 CO CG-DRUG-50 Paclitaxel, protein-bound (Abraxane ) Precription Drug 1/1/2017 5/10/2018 CO CG-DRUG-51 Romidepsin (Istodax ) Precription Drug 1/1/2017 6/6/2018 CO CG-DRUG-54 Agalsidase beta (Fabrazyme ) Precription Drug 5/1/2017 2/28/2018 CO CG-DRUG-55 Elosulfase alfa (Vimizim ) Precription Drug 5/1/ /17/2018 CO CG-DRUG-56 Galsulfase (Naglazyme ) Precription Drug 5/1/2017 8/29/2018 CO CG-DRUG-57 Idursulfase (Elaprase ) Precription Drug 5/1/2017 4/25/2018 CO CG-DRUG-58 Laronidase (Aldurzyme ) Precription Drug 5/1/ /27/2017 CO CG-DRUG-61 Gonadotropin Releasing Hormone Analogs for the Treatment of Non- Precription Drug 5/1/ /27/2017 Oncologic Indications CO CG-DRUG-62 Fulvestrant (Faslodex ) Precription Drug 5/1/2017 6/6/2018 CO CG-DRUG-63 Levoleucovorin Calcium (Fusilev ) Precription Drug 5/1/ /27/2017 CO CG-DRUG-64 FDA-Approved Biosimilar Products Precription Drug 11/17/2016 6/28/2018 CO CG-DRUG-65 Tumor Necrosis Factor Antagonists Precription Drug 12/27/2017 8/29/2018 CO CG-DRUG-66 Panitumumab (Vectibix ) Precription Drug 12/27/ /27/2017 CO CG-DRUG-67 Cetuximab (Erbitux ) Precription Drug 6/28/2018 6/28/2018 CO CG-DRUG-68 Bevacizumab (Avastin ) for Non-Opthalmologic Indications Precription Drug 12/27/2017 8/29/2018 CO CG-DRUG-69 Ustekinumab (Stelara ) Precription Drug 12/27/2017 8/29/2018 Revised:April 1, 2018 (SKJ) Page 1 of 5

2 CO CG-DRUG-70 Eribulin mesylate (Halaven ) Precription Drug 12/27/ /27/2017 CO CG-DRUG-71 Ziv-aflibercept (Zaltrap ) Precription Drug 12/27/ /27/2017 CO CG-DRUG-72 Pertuzumab (Perjeta ) Precription Drug 12/27/2017 8/29/2018 CO CG-DRUG-73 Denosumab (Prolia, Xgeva ) Precription Drug 12/27/2017 8/29/2018 CO CG-DRUG-74 Canakinumab (Ilaris ) Precription Drug 12/27/ /17/2018 CO CG-DRUG-75 Romiplostim (Nplate ) Precription Drug 12/27/ /27/2017 CO CG-DRUG-76 Plerixafor Injection (Mozobil ) Precription Drug 12/27/ /27/2017 CO CG-DRUG-77 Radium Ra 223 Dichloride (Xofigo ) Precription Drug 12/27/ /27/2017 CO CG-DRUG-78 Antihemophilic Factor and Clotting Factors Precription Drug 12/27/2017 6/6/2018 CO CG-DRUG-79 Siltuximab (Sylvant ) Precription Drug 12/27/ /27/2017 CO CG-DRUG-80 Cabazitaxel (Jevtana ) Precription Drug 12/27/ /27/2017 CO CG-DRUG-81 Tocilizumab (Actemra*) Precription Drug 12/27/2017 8/29/2018 CO CG-DRUG-82 Prostacyclin Infusion Therapy and Inhalation Therapy for Treatment of Precription Drug 5/1/2018 5/1/2018 Pulmonary Arterial Hypertension CO CG-DRUG-83 Growth Hormone Precription Drug 5/1/2018 5/1/2018 CO CG-DRUG-84 Belimumab (Benlysta ) Precription Drug 5/1/2018 5/1/2018 CO CG-DRUG-85 Tesamorelin (Egrifta ) Precription Drug 5/1/2018 5/1/2018 CO CG-DRUG-86 Ocriplasmin (Jetrea ) Intravitreal Injection Treatment Precription Drug 5/1/2018 5/1/2018 CO CG-DRUG-87 Vedolizumab (Entyvio ) Precription Drug 5/1/2018 5/1/2018 CO CG-DRUG-88 Dupilumab (Dupixent ) Precription Drug 5/1/2018 5/1/2018 CO CG-DRUG-89 Implantable and Extended-Release Buprenorphine-Containing Products Precription Drug 6/22/2018 6/22/2018 CO CG-DRUG-90 Intravitreal Treatment for Retinal Vascular Conditions Precription Drug 6/28/2018 8/29/2018 CO CG-DRUG-91 Intravitreal Corticosteroid Implants Precription Drug 6/28/2018 6/28/2018 CO CG-DRUG-92 Alpha-1 Proteinase Inhibitor Therapy Precription Drug 6/28/2018 6/28/2018 CO CG-DRUG-93 Sarilumab (Kevzara ) Precription Drug 6/28/2018 6/28/2018 CO CG-DRUG-94 Rituximab (Rituxan ) for Non-Oncologic Indications Precription Drug 6/28/ /17/2018 CO CG-DRUG-95 Belatacept (Nulojix ) Precription Drug 6/28/2018 6/28/2018 CO CG-DRUG-96 Ado-trastuzumab emtansine (Kadcyla ) Precription Drug 6/28/2018 6/28/2018 CO CG-DRUG-97 Rilonacept (Arcalyst ) Precription Drug 6/28/2018 6/28/2018 CO CG-DRUG-98 Bendamustine Hydrochloride Precription Drug 6/28/2018 6/28/2018 CO CG-DRUG-99 Elotuzumab (Empliciti ) Precription Drug 6/28/2018 6/28/2018 CO CG-DRUG-100 Interferon gamma-1b (Actimmune ) Precription Drug 6/28/2018 6/28/2018 CO CG-DRUG-101 Ixabepilone (Ixempra ) Precription Drug 6/28/2018 6/28/2018 CO CG-DRUG-102 Olaratumab (Lartruvo ) Precription Drug 6/28/2018 6/28/2018 CO CG-DRUG-103 Botulism Toxin Precription Drug 9/20/2018 9/20/2018 CO CG-DRUG-104 Omalizumab (Xolair ) Precription Drug 9/20/2018 9/20/2018 CO CG-DRUG-105 Abatacept (Orencia) Precription Drug 9/20/2018 9/20/2018 CO CG-DRUG-106 Brentuximab Vedotin (Adcetris ) Precription Drug 9/20/2018 9/20/2018 CO CG-DRUG-107 Pharmacotherapy for Hereditary Angioedema Precription Drug 9/20/2018 9/20/2018 CO CG-DRUG-108 Enteral Carbidopa and Levodopa Intestinal Gel Suspension Precription Drug 9/20/2018 9/20/2018 CO CG-DRUG-109 Asfotase Alfa (Strensiq ) Precription Drug 9/20/2018 9/20/2018 CO CG-DRUG-110 Naltrexone Implantable Pellets Precription Drug 9/20/2018 9/20/2018 CO CG-DRUG-111 Sebelipase alfa (KANUMA ) Precription Drug 9/20/2018 9/20/2018 CO CG-DRUG-112 Abaloparatide (Tymlos) Precription Drug 9/20/2018 9/20/2018 CO CG-GENE-01 Janus Kinase 2 (JAK2) V617F Gene Mutation Assay Genetics 12/27/ /27/2017 CO CG-GENE-02 Analysis of KRAS Status Genetics 12/27/2017 8/29/2018 CO CG-GENE-03 BRAF Mutation Analysis Genetics 12/27/2017 8/29/2018 CO CG-GENE-04 Molecular Marker Evaluation of Thyroid Nodules Genetics 12/27/2017 8/29/2018 CO CG-LAB-03 Tropism Testing for HIV Management Laboratory 7/9/2013 4/25/2018 CO CG-LAB-11 Screening for Vitamin D Deficiency in Average Risk Individuals Laboratory 2/1/2018 4/1/2018 CO CG-LAB-13 Skin Nerve Fiber Density Testing Laboratory 6/28/2018 6/28/2018 CO CG-MED-23 Home Health Care Medicine 6/1/2014 3/29/2018 CO CG-MED-26 Neonatal Levels of Care Medicine 8/12/2013 8/29/2018 CO CG-MED-32 Ancillary Services for Pregnancy Complications Medicine 4/16/2013 3/29/2018 CO CG-MED-37 Intensive Programs for Pediatric Feeding Disorders Medicine 4/1/2017 6/6/2018 CO CG-MED-38 Inpatient Admission for Radiation Therapy for Cervical or Thyroid Medicine 6/1/2018 6/1/2018 Cancer CO CG-MED-39 Central (Hip or Spine) Bone Density Measurement and Screening for Vertebral Fractures Using Dual Energy X-Ray Absorptiometry Medicine 1/8/2013 2/28/2018 CO CG-MED-46 Ambulatory and Inpatient Video Electroencephalography Medicine 2/1/ /27/2017 CO CG-MED-53 Cervical Cancer Screening Using Cytology and Human Papillomavirus Medicine 1/1/2018 2/28/2018 Testing CO CG-MED-55 Level of Care: Advanced Radiologic Imaging Medicine 9/1/2017 4/25/2018 CO CG-MED-58 Coronary Artery Imaging: Contrast Enhanced CT Angiography, Fractional Flow Reserve derived from CT, Coronary MRA, and Cardiac MRI Medicine 12/27/2017 9/15/2017 Transition to AIM Radiology Guidelines 01/01/2019 CO CG-MED-59 Upper Gastrointestional Endoscopy Medicine 11/1/ /1/2018 CO CG-MED-63 Treatment of Hyperhidrosis Medicine 12/27/ /17/2018 CO CG-MED-64 Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation or Atrial Flutter (Radiofrequency and Cryoablation) Medicine 12/27/ /17/2018 CO CG-MED-65 Manipulation Under Anesthesia of the Spine and Joints other than the Medicine 12/27/ /27/2017 Knee CO CG-MED-66 Cryopreservation of Oocytes or Ovarian Tissue Medicine 12/27/ /27/2017 CO CG-MED-67 Melanoma Vaccines Medicine 12/27/ /27/2017 CO CG-MED-68 Therapeutic Apheresis Medicine 12/27/2017 4/25/2018 Revised:April 1, 2018 (SKJ) Page 2 of 5

3 CO CG-MED-69 Inhaled Nitric Oxide Medicine 6/28/2018 6/28/2018 CO CG-MED-70 Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Medicine 6/28/2018 6/28/2018 Patency Capsule CO CG-MED-72 Hyperthermia for Cancer Therapy Medicine 6/28/2018 6/28/2018 CO CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical) Medicine 9/20/2018 9/20/2018 CO CG-MED-74 Implantable Ambulatory Event Monitors and Mobile Cardiac Medicine 9/20/2018 9/20/2018 Telemetry CO CG-MED-75 Medical and Other Non-Behavioral Health Related Treatments for Medicine 9/20/2018 9/20/2018 Autism Spectrum Disorders and Rett Syndrome CO CG-MED-76 Medical and Other Non-Behavioral Health Related Treatments for Medicine 9/20/2018 9/20/2018 Autism Spectrum Disorders and Rett Syndrome CO CG-MED-77 SPECT/CT Fusion Imaging Medicine 9/20/2018 9/20/2018 CO CG-OR-PR-05 Myoelectric Upper Extremity Prosthetic Devices Orthotics/Prosthetics 4/15/2014 3/29/2018 CO CG-REHAB-04 Physical Therapy Rehabilitation 11/1/2015 4/25/2018 CO CG-REHAB-05 Occupational Therapy Rehabilitation 11/1/2015 6/6/2018 CO CG-REHAB-07 Skilled Nursing and Skilled Rehabilitation Services (Outpatient) Rehabilitation 4/16/2013 3/29/2018 CO CG-REHAB-08 Private Duty Nursing in the Home Setting Rehabilitation 4/16/2013 8/29/2018 CO CG-REHAB-11 Cognitive Rehabilitation Rehabilitation 9/20/2018 9/20/2018 CO CG-SURG-03 Blepharoplasty, Blepharoptosis Repair, and Brow Lift Surgery 4/16/2013 3/29/2018 CO CG-SURG-05 Maze Procedure Surgery 10/9/2012 9/27/2017 CO CG-SURG-08 Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary Spinal Cord Injury Surgery 10/9/2012 9/27/2017 CO CG-SURG-09 Temporomandibular Disorders Pre Service: CPT Codes 20605, 21010, Surgery 1/8/2013 4/25/ , 21060, 21073, 21116, 21210, 21240, 21242, 21243, 29800, 29804; HCPCS Codes D7810, D7820, D7830, D7840, D7850, D7852, D7854, D7856, D7858, D7860, D7865, D7870, D7881, D7873, D7874, D7875, D7876, D7877 CO CG-SURG-12 Penile Prosthesis Implantation CPT Codes 54400, 5401, 54405, 54410, Surgery 1/8/2013 9/27/ , 54416, CO CG-SURG-18 Septoplasty 30420, 30520, Surgery 10/9/2012 6/6/2018 CO CG-SURG-24 Functional Endoscopic Sinus Surgery (FESS) Surgery 10/9/ /27/2017 CO CG-SURG-27 Sex Re-Assignment Surgery Pre Service: CPT Codes 54125, 54520, Surgery 10/9/2012 4/25/ , 55180, 55970, 56625, 55980, 56800, 56805, 57110, 57291, 57292, 57295, 57296, CO CG-SURG-28 Transcatheter Uterine Artery Embolization Surgery 1/8/ /27/2017 CO CG-SURG-29 Lumbar Discography (Split from CG RAD-06 Surgery 5/13/2013 3/29/2018 CO CG-SURG-30 Tonsillectomy for Children With or Without Adenoidectomy Surgery 10/9/2012 6/6/2018 CO CG-SURG-33 Lumbar Fusion and Lumbar Total Disc Arthroplasty Surgery 5/13/2013 2/28/2018 CO CG-SURG-38 Lumbar Laminectomy, Hemi-Laminectomy, Laminotomy and/or Surgery 11/14/ /27/2017 Discectomy CO CG-SURG-42 Cervical Fusion Surgery 5/1/ /27/2017 CO CG-SURG-44 Coronary Angiography and Cardiac Catheterization in the Outpatient Surgery 3/1/2016 9/27/2017 Setting CO CG-SURG-47 Surgical Interventions for Scoliosis and Spinal Deformity Surgery 6/15/ /27/2017 CO CG-SURG-48 Elective Percutaneous Coronary Interventions (PCI) Surgery 3/1/ /27/2017 CO CG-SURG-53 Elective Total Hip Arthroplasty Surgery 6/15/ /27/2017 CO CG-SURG-54 Elective Total Knee Arhtroplasty Surgery 6/15/ /27/2017 CO CG-SURG-60 Cervical Total Disc Arthroplasty Surgery 1/1/2018 3/29/2018 CO CG-SURG-61 Cryosurgical Ablation of Solid Tumors Outside the Liver Surgery 12/27/ /27/2017 CO CG-SURG-62 Radiofrequency Ablation to Treat Tumors Outside the Liver Surgery 12/27/ /27/2017 CO CG-SURG-63 Cardiac Resynchronization Therapy (CRT) with or without an Surgery 12/27/ /27/2017 Implantable Cardioverter Defibrillator (CRT/ICD) for the Treatment of Heart Failure CO CG-SURG-65 Recombinant Human Bone Morphogenetic Protein Surgery 12/27/ /27/2017 CO CG-SURG-66 Implanted (Epidural and Subcutaneous) Spinal Cord Stimulators (SCS) Surgery 12/27/ /27/2017 CO CG-SURG-67 Treatment of Osteochondral Defects Surgery 12/27/ /27/2017 CO CG-SURG-68 Surgical Treatment of Femoroacetabular Impingement Syndrome Surgery 12/27/ /27/2017 CO CG-SURG-69 Meniscal Allograft Transplantation of the Knee Surgery 12/27/ /27/2017 CO CG-SURG-70 Gastric Electrical Stimulation Surgery 5/1/2018 5/1/2018 CO CG-SURG-71 Reduction Mammaplasty Surgery 5/1/2018 5/1/2018 CO CG-SURG-72 Endothelial Keratoplasty Surgery 5/1/2018 5/1/2018 CO CG-SURG-73 Balloon Sinus Ostial Dilation Surgery 8/2/2018 8/2/2018 CO CG-SURG-74 Total Ankle Replacement Surgery 6/28/2018 6/28/2018 CO CG-SURG-75 Transanal Endoscopic Microsurgical (TEM) Excision of Recal Lesions Surgery 6/28/2018 6/28/2018 CO CG-SURG-76 Carotid, Vertebral and Intracranial Artery Stent Placement with or Surgery 6/28/2018 6/28/2018 without Angioplasty CO CG-SURG-77 Refractive Surgery Surgery 6/28/2018 6/28/2018 CO CG-SURG-78 Locally Ablative Techniques for Treating Primary and Metastatic Liver Surgery 6/28/2018 6/28/2018 Malignancies CO CG-SURG-79 Implantable Infusion Pumps Surgery 6/28/2018 6/28/2018 CO CG-SURG-80 Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Surgery 6/28/2018 6/28/2018 Arterial Embolization (TAE) for Treating Primary or Metastatic Liver Tumors CO CG-SURG-81 Cochlear Implants and Auditory Brainstem Implants Surgery 9/20/2018 9/20/2018 CO CG-SURG-82 Bone-Anchored and Bone Conduction Hearing Aids Surgery 9/20/2018 9/20/2018 CO CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity Surgery 10/31/ /31/2018 CO CG-SURG-84 Mandibular/ Maxillary (Orthognathic) Surgery Surgery 9/20/2018 9/20/2018 CO CG-SURG-85 Hip Resurfacing Surgery 10/31/ /31/2018 CO CG-SURG-86 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Surgery 10/31/ /31/2018 Disease, Aortic Dissection and Aortic Transection CO CG-SURG-87 Nasal Surgery for the Treatment of Obstructive Sleep Apnea and Snoring Surgery 9/20/2018 9/20/2018 Revised:April 1, 2018 (SKJ) Page 3 of 5

4 CO CG-SURG-88 Mastectomy for Gynecomastia Surgery 9/20/2018 9/20/2018 CO CG-SURG-89 Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Surgery 8/29/2018 8/29/2018 Trigeminal Neuralgia CO CG-THER-RAD-03 Intravascular Brachytherapy (Coronary and Noncoronary) Therapeutic Radiology 7/1/2018 8/29/2018 CO CG-THER-RAD-07 Intravascular Brachytherapy (Coronary and Noncoronary) Therapeutic Radiology 6/28/2018 6/28/2018 CO CG-TRANS-02 Kidney Transplantation Transplants 1/8/2013 4/25/2018 Revised:April 1, 2018 (SKJ) Page 4 of 5

5 AIM Specialty Health (AIM) AIM Specialty Health, a subsidiary of Anthem, Inc., is a nationally recognized leader that designs and administers specialty benefits management programs on behalf of Anthem for certain health plan members. To determine if preapproval for a test or treatment is needed for a participating Anthem member, click on the Medical Policy, Clinical UM Guidelines, and Preapproval Requirements link included on the provider website, or call the preapproval phone number printed on the back of the member s ID card. To submit your request for clinical review of any of the services below, use the free, secure AIM ProviderPortalSM at From the drop-down menu, select your state and then proceed entering member and clinical information. You may also call AIM toll-free at , Monday Friday, (9:00 a.m. 7:00 p.m. CT). AIM administers the following programs for Anthem: * Radiology Benefit Management including Imaging Level of Care * Genetic Testing * Diagnostic Imaging Management * Cardiovascular Services * Radiation Therapy Services * Outpatient Sleep Testing and Therapy Services * Specialty Pharmacy Drugs (VA is currently administering this program in their region) * Cancer Care Quality Program * Musculoskeletal (Not available in all markets at this time) For more details on these programs and their clinical guidelines, please visit the AIM Specialty Health Site with links to Anthem programs By clicking on the link above, you will be linked to sites created and/or maintained by another, separate entity ( External Site ). Upon linking you are subject to the terms of use, privacy, copyright and security policies of the External Sites. We provide these links solely for your information and convenience. We encourage you to review the privacy practices of the External Sites. * Original Implementation Date by state - this is the original implementation date by the health plan ** Current Version's Implementation Date - this is the date the health plan will begin using the current published version for reviews Notes: For a complete listing of Anthem Medical Policies and Clinical UM Guidelines, please go to: Anthem Provider Site > select your state> Scroll down page, click See Policies and Guidelines Revised:April 1, 2018 (SKJ) Page 5 of 5